ORCID Profile
0000-0002-6157-8880
Current Organisations
The University of Newcastle
,
Belmont Hospital
,
Australian Commission on Safety and Quality in Health Care
,
Australian Commission on Safety and Quality in Healthcare
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Publications
Process quality indicators for musculoskeletal injuries in the emergency department
Publisher: BMJ
Date: 22-10-2019
DOI: 10.1136/EMERMED-2019-208531
Abstract: Measuring quality of care for musculoskeletal injuries presenting to the ED is important given their prevalence, variations in care, the associated morbidity and financial impacts and pressure to achieve time-based performance measures. Process quality indicators (QIs) provide a quantitative method to measure the actions taken during healthcare delivery. This study aimed to develop a set of process QIs to measure the quality of care for musculoskeletal injuries in the ED. A multiphase mixed-methods study was undertaken from 2015 to 2018, commencing with a systematic review to identify existing musculoskeletal QIs. This review, along with current evidence regarding musculoskeletal injury management in the ED, informed an expert panel who developed a preliminary set of process QIs. The preliminary set was field tested at eight EDs in Queensland, Australia, to determine the validity, reliability, feasibility and usefulness of each QI. Prospective observational data collection and retrospective chart audits were used to score the process QIs. These results were presented to the expert panel who determined a final QI set. A total of 633 patients were recruited and 36 process QIs included in the final set. The QIs covered important domains of pain assessment and management, history taking and physical examination, appropriateness and timeliness of imaging, fracture management, mobility, patient information and discharge considerations including safety and referrals. The best performing QIs included the use of opioid sparing analgesics and avoiding prescription of ‘just in case’ opioids at discharge. The poorest performing QIs included the completion of spinal red flag questioning and referrals for fragility fractures. An evidence and best practice-based set of QIs has been developed to allow EDs to assess and quantify the quality of care for musculoskeletal presentations. This will allow EDs to compare and benchmark, leading to the optimisation of care for patients.
Knowledge and confidence of junior medical doctors in discussing and documenting resuscitation plans: a cross‐sectional survey
Publisher: Wiley
Date: 12-2021
DOI: 10.1111/IMJ.14994
Abstract: A resuscitation plan is a medically authorised order to use or withhold resuscitation interventions. Absence of appropriate resuscitation orders exposes patients to the risk of invasive medical interventions that may be of questionable benefit depending on in idual circumstances. To describe among junior doctors: (i) self‐reported confidence discussing and completing resuscitation plans (ii) knowledge of resuscitation policy including whether resuscitation plans are legally enforceable and key triggers for completion and (iii) the factors associated with higher knowledge of triggers for completing resuscitation plans. A cross‐sectional survey was conducted at five hospitals. Junior doctors on clinical rotation were approached at scheduled training sessions, before or after ward rounds or at change of rotation orientation days and provided with a pen‐and‐paper survey. A total of 118 junior doctors participated. Most felt confident discussing (79% n = 92) and documenting (87% n = 102) resuscitation plans with patients. However, only 45% ( n = 52) of doctors correctly identified that resuscitation plans are legally enforceable medical orders. On average, doctors correctly identified 6.8 (standard deviation = 1.8) out of 10 triggers for completing a resuscitation plan. Doctors aged years were four times more likely to have high knowledge of triggers for completing resuscitation plans (odds ratio 4.28 (95% confidence interval 1.54–11.89) P = 0.0053). Most junior doctors feel confident discussing and documenting resuscitation plans. There is a need to improve knowledge about legal obligations to follow completed resuscitation plans, and about when resuscitation plans should be completed to ensure they are completed with patients who are most at risk.
Abuse of the older person
Publisher: Wiley
Date: 08-03-2017
Approach to death in the older emergency department patient
Publisher: Wiley
Date: 29-09-2016
Cost analysis of an integrated aged care program for residential aged care facilities
Publisher: CSIRO Publishing
Date: 2019
DOI: 10.1071/AH16297
Abstract: Objective To compare annual costs of an intervention for acutely unwell older residents in residential age care facilities (RACFs) with usual care. The intervention, the Aged Care Emergency (ACE) program, includes telephone clinical support aimed to reduce avoidable emergency department (ED) presentations by RACF residents. Methods This costing of the ACE intervention examines the perspective of service providers: RACFs, Hunter Medicare Local, the Ambulance Service of New South Wales, and EDs in the Hunter New England Local Health District. ACE was implemented in 69 RACFs in the Hunter region of NSW, Australia. Analysis used 14 weeks of ACE and ED service data (June–September 2014). The main outcome measure was the net cost and saving from ACE compared with usual care. It is based on the opportunity cost of implementing ACE and the opportunity savings of ED presentations avoided. Results Our analysis estimated that 981 avoided ED presentations could be attributed to ACE annually. Compared with usual care, ACE saved an estimated A$921214. Conclusions The ACE service supported a reduction in avoidable ED presentations and ambulance transfers among RACF residents. It generated a cost saving to health service providers, allowing reallocation of healthcare resources. What is known about the topic? Residents from RACFs are at risk of further deterioration when admitted to hospital, with high rates of delirium, falls, and medication errors. For this cohort, some conditions can be managed in the RACF without hospital transfer. By addressing avoidable presentations to EDs there is an opportunity to improve ED efficiency as well as providing care that is consistent with the resident’s goals of care. RACFs generate some avoidable ED presentations for residents who may be more appropriately treated in situ. What does this paper add? Telephone triaging with nursing support and training is a means by which ED presentations from RACFs can be reduced. One of the consequences of this intervention is ‘cost avoided’, largely through savings on ambulance costs. What are the implications for practitioners? Unnecessary transfer from RACFs to ED can be avoided through a multicomponent program that includes telephone support with cost-saving implications for EDs and ambulance services.
Multidisciplinary analysis of invasive meningococcal disease as a framework for continuous quality and safety improvement in regional Australia
Publisher: BMJ
Date: 02-2018
DOI: 10.1136/BMJOQ-2017-000077
Abstract: System factors in a regional Australian health district contributed to avoidable care deviations from invasive meningococcal disease (IMD) management guidelines. Traditional root cause analysis (RCA) is not well-suited to IMD, focusing on in idual cases rather than system improvements. As IMD requires complex care across healthcare silos, it presents an opportunity to explore and address system-based patient safety issues. Baseline assessment of IMD cases (2005–2006) identified inadequate triage, lack of senior clinician review, inconsistent vital sign recording and laboratory delays as common issues, resulting in antibiotic administration delays and inappropriate or premature discharge. Clinical governance, in partnership with clinical and public health services, established a multidisciplinary Meningococcal Reference Group (MRG) to routinely review management of all IMD cases. The MRG comprised representatives from primary care, acute care, public health, laboratory medicine and clinical governance. Baseline data were compared with two subsequent evaluation points (2011–2012 and 2013–2015). Phase I involved multidisciplinary process mapping and development of a standardised audit tool from national IMD management guidelines. Phase II involved formalisation of group processes and advocacy for operational change. Phase III focused on dissemination of findings to clinicians and managers. Greatest care improvements were observed in the final evaluation. Median antibiotic delay decreased from 72 to 42 min and proportion of cases triaged appropriately improved from 38% to 75% between 2013 and 2015. Increasing fatal outcomes were attributed to the emergence of more virulent meningococcal serotypes. The MRG was a key mechanism for identifying system gaps, advocating for change and enhancing communication and coordination across services. Employing IMD case review as a focus for district-level process reflection presents an innovative patient safety approach, combining the strengths of prospective hazard analysis with more traditional RCA methodologies.
Validation of a point of care troponin assay in real life emergency department conditions
Publisher: Wiley
Date: 29-07-2009
DOI: 10.1111/J.1742-6723.2009.01198.X
Abstract: To validate the accuracy of a Point of care (POC) troponin device (Abbott i-Stat) in real life ED conditions. A three-way comparison between troponin I results obtained by experienced POC operators, inexperienced ED staff and central laboratory criterion standard. Convenience s le of 332 patients presenting to the ED with possible coronary syndromes. Spearman correlation coefficient for experienced versus laboratory was 0.83 (95% CI 0.78-0.87), occasional users versus laboratory was 0.76 (95% CI 0.71-0.81), and experienced versus occasional users on POC was 0.82 (95% CI 0.76-0.87). Using local troponin cut-off of 0.1 ng/mL, kappa coefficient was 0.94 for occasional users versus laboratory, 0.91 for experienced versus laboratory and 0.94 for experienced versus occasional users. Bland-Altman plots showed good agreement across the range of measured values. The sensitivity of i-Stat (vs laboratory as criterion standard) was 92.2% (95% CI 83.8%-97.0%) with the local cut-off but only 70.1% (95% CI 60.5%-78.6%) using the lowest cut-off associated with acceptable reproducibility (10% coefficient of variation). The i-Stat POC device produces similar results in the hands of experienced and occasional operators in ED. There is good agreement between the POC and laboratory at levels used to diagnose infarction by older, more specific criteria. When compared using new lower cut-offs, the i-Stat had poor sensitivity.
Droperidol should not be considered first line therapy in acute behavioural disturbance of older patients
Publisher: Wiley
Date: 09-02-2021
Holistic approach to undifferentiated acute severe behavioural disturbance in older emergency department patients
Publisher: Wiley
Date: 17-09-2021
Avoiding anchoring bias by moving beyond ‘mechanical falls’ in geriatric emergency medicine
Publisher: Wiley
Date: 08-08-2018
Caring for acutely unwell older residents in residential aged‐care facilities: Perspectives of staff and general practitioners
Publisher: Wiley
Date: 09-06-2015
DOI: 10.1111/AJAG.12221
Abstract: To explore the challenges and facilitators of managing acutely unwell residents in their residential aged-care facilities (RACF) and transferring RACF residents to the emergency department of a tertiary referral hospital in Australia. This exploratory study used a qualitative descriptive approach incorporating structured focus group interviews with nursing staff from RACFs and General Practitioners (GPs) within the local area. Four focus groups were held with staff from RACFs and one with GPs who visited one or more of the facilities during 2010. The interview data were analysed for themes relating to the study aims. Findings revealed both challenges and facilitators associated with managing acutely unwell older people including, communication, nursing staffing mix and numbers, use of advanced care directives, responsibilities of GPs and awareness of community services. From these findings it is possible to make recommendations for alternative ways of practising and/or new models of care.
Shores Revised Westmead Post-Traumatic Amnesia Scale
Publisher: No publisher found
Date: 2014
DOI: 10.1037/T28517-000
An assistant workforce to improve screening rates and quality of care for older patients in the emergency department: findings of a pre- post, mixed methods study
Publisher: Springer Science and Business Media LLC
Date: 30-05-2018
Is delirium the medical emergency we know least about?
Publisher: Wiley
Date: 24-07-2016
Emergency department pain management in older patients
Publisher: Wiley
Date: 27-06-2020
Assessment of advance care planning documentation for residents of residential aged care facilities presenting to the emergency department
Publisher: CSIRO Publishing
Date: 2020
DOI: 10.1071/AH19238
Abstract: ObjectiveThis study assessed the availability and quality of advance care planning (ACP) documentation among older residential aged care facility (RACF) residents who presented to the emergency department (ED). MethodsA prospective review of the medical records of RACF residents aged ≥75 years who presented to the ED from May to June 2018 was conducted. Availability of ACP was determined based on the presence of an ACP document inclusive of an advance care directive (ACD) in the medical record. The quality of ACP documentation was determined based on the presence of nine key components. ResultsIn all, 48.8% of patients presented to the ED with either ACP or an ACD. However, only a mean total of 3.8 (out of 9) ACP components were documented in these documents. ConclusionsJust under half (48.8%) of RACF residents presented to the ED with ACP documentation. There was limited coverage of core ACP components needed to guide clinical decision making. What is known about the topic?RACF residents are in the last years of their life and commonly lack capacity to make decisions regarding health care. Residents are at high risk of dying when acutely unwell in hospital. ACP documentation, when readily available, helps provide appropriate end-of-life care and improves both patient and family satisfaction. What does this paper add?Less than half the residents reporting to the ED from an RACF had ACP documentation available for clinicians. For those who presented to the ED with ACP documentation, most lacked sufficient information needed to provide care in full accordance with the patient’s preferences. What are the implications for practitioners?There is a need to encourage, initiate, actively engage and develop systems for ACP conversations, documentation and availability when acutely unwell for people living in RACFs to provide sufficient information to guide clinical decision making. Without quality ACP, the provision of patient-centred health care may be compromised.
Supporting residential aged care through a Community of Practice
Publisher: Wiley
Date: 08-01-2022
DOI: 10.1111/NHS.12917
Abstract: Transfers to emergency departments and hospitalizations are common for older people living in residential aged care who experience acute deterioration. This paper shares reflections from 10 years of work across a region in New South Wales, Australia, to develop a new model of care in 141 residential aged care homes. The model successfully reduced emergency department transfers and admissions to hospital. Using an exemplar patient case, the paper describes the Aged Care Emergency Program and associated research outputs. An interprofessional, multiagency Community of Practice supported this work. The authors reflect on the successes and challenges of using a Community of Practice to implement the model of care. We conclude that the Community of Practice, with its iterative evaluation, facilitated change and provided a mechanism for interprofessional practice. Broader systemic change requires clarity in goals of care, shared decision‐making, working across sectors, and appropriate resource allocation.
Adverse outcomes following emergency department discharge of patients with possible acute coronary syndrome
Publisher: Wiley
Date: 24-11-2009
DOI: 10.1111/J.1742-6723.2009.01229.X
Abstract: To determine the proportion of adverse events in patients discharged after ED assessment for possible acute coronary syndrome. Prospective observational cohort study enrolling consecutive patients presenting with symptoms suggestive of coronary syndrome. Main outcome was the proportion of adverse coronary events (defined a priori) within 30 days. Of 2627 patients, 1819 (69%) were discharged without a diagnosis of coronary syndrome and 808 (31%) were admitted for further investigation and treatment. Of these, 385 (14.7%) were given a final diagnosis of acute coronary syndrome. On 30 day follow up, 18 of the discharged patients were diagnosed with acute coronary syndrome (0.7% 95% confidence intervals [CI] 0.4-1.1%), 10 with unstable angina (0.4% 95% CI 0.2-0.7%) and 8 with non-ST elevation myocardial infarction (0.3% 95% CI 0.2-0.6%). There were no cases of ST elevation infarction or death. The sensitivity for diagnosis of acute coronary syndromes was 95.5% (95% CI 92.9-97.3%). Average length of stay was 7 h for discharged patients. Forty-six per cent of patients with diabetes and 47% with a past history of coronary disease were discharged. Subsequent outpatient stress testing was performed in 13.6%. In a large Australian ED, less than 1% of patients presenting with symptoms suggestive of coronary syndrome were discharged and subsequently had a 30 day adverse event. Reducing this proportion by admitting patients with traditional risk factors would markedly increase hospital workload. Opportunities exist to improve both the safety and efficiency of chest pain assessment in the ED.
Musculoskeletal injury quality outcome indicators for the emergency department
Publisher: Springer Science and Business Media LLC
Date: 26-11-2019
DOI: 10.1007/S11739-019-02234-W
Abstract: High standards of care for musculoskeletal injuries presenting to emergency departments (ED) must be maintained despite financial constraints, the model of care in place, or the pressure to reach time-based performance measures. Outcome quality indicators (QIs) provide a tangible way of assessing and improving the outcomes of health-care delivery. This study aimed to develop a set of outcome QIs for musculoskeletal injuries in the ED that are meaningful, valid, feasible to collect, simple to use for clinical quality improvement and chosen by experts in the field. The study used a multi-phase mixed methods design, commencing with a systematic review of available outcome QIs. An expert panel then developed a set of preliminary QIs based on the available scientific evidence. Prospective observational data collection was undertaken across eight EDs with subsequent retrospective chart audits, follow-up phone calls and audit of administrative databases. After statistical analysis, validated results were presented to the expert panel who discussed, refined and formally voted on a final outcome QI set. A total of 41 preliminary outcome QIs were field tested in EDs, with data collected on 633 patients. Using the field study results, the expert panel voted 11 outcome QIs into the final set. These covered effectiveness of pain management, timeliness to discharge, re-presentations to the ED and unplanned visits to health professionals in the community, missed injuries, opioids side effects and the patient experience. An evidence-based set of outcome quality indicators is now available to support clinical quality improvement of musculoskeletal injury care in the ED setting.
The diagnostic accuracy of the Revised Westmead PTA Scale as an adjunct to the Glasgow Coma Scale in the early identification of cognitive impairment in patients with mild traumatic brain injury
Publisher: BMJ
Date: 10-2008
Abstract: Assessment of patients with mild traumatic brain injury (mTBI) is predominantly done using the Glasgow Coma Scale (GCS). While the GCS is universally accepted for assessment of severity of traumatic brain injury, it may not be appropriate to rely on the GCS alone when assessing patients with mTBI in prehospital settings and emergency departments. To determine whether administering the Revised Westmead Post-traumatic Amnesia (PTA) Scale (R-WPTAS) in addition to the GCS would increase diagnostic accuracy in the early identification of cognitive impairment in patients with mTBI. Data were collected from 82 consecutive participants with mTBI who presented to the emergency department of a level 1 trauma centre in Australia. A matched s le of 88 control participants who attended the emergency department for reasons other than head trauma was also assessed. All patients were assessed using the GCS, R-WPTAS and a battery of neuropsychological tests. Patients with mTBI scored poorly compared with control patients on all measures. The R-WPTAS showed greater concurrent validity with the neuropsychological measures than the GCS and significantly increased prediction of group membership of patients with mTBI with cognitive impairment. The R-WPTAS significantly improves diagnostic accuracy in identifying patients with mTBI who may be in PTA. Administration takes less than 1 min, and since early identification of a patient's cognitive status facilitates management decisions, it is recommended for routine use whenever the GCS is used.
Clinical pharmacist review: A randomised controlled trial
Publisher: Wiley
Date: 19-07-2015
Abstract: To determine if medication review by a clinical pharmacist of older patients in the ED impacted on admission to hospital and other outcomes. A stratified, randomised controlled study comparing the intervention to current practice. A tertiary referral ED in New South Wales, Australia. Older people (>70 years) living at home who initially reported taking greater than five medications. Medication review by an experienced hospital pharmacist within the ED. Rate of admission, rate of readmission, length of stay and admission to an aged care facility at 4 months post presentation, and rate of general practitioner acceptance of pharmacist recommendations. The odds of admission decreased for those receiving the intervention (odds ratio [OR] = 0.68, 95% confidence interval [CI]: 0.53, 0.87 P = 0.002). There was no evidence that the intervention affected hospital length of stay for admitted patients (0.09 days change, 95% CI -0.08, 0.25 P = 0.31), the rate of re-presentation (0.08% change, 95% CI -0.12, 0.28 P = 0.44) or admission to an aged care facility. The odds of admission to an aged care facility increased with the Identification of Seniors at Risk score. General practitioners adopted 49% of pharmacists' recommendations. The presence of an experienced pharmacist in the ED reduced hospital admissions. Further study is required to determine longer term impacts of General Medical Practitioner acceptance of pharmacists' recommendations.
Structural quality indicators to support quality of care for older people with cognitive impairment in emergency departments
Publisher: Wiley
Date: 03-2015
DOI: 10.1111/ACEM.12617
Abstract: The purpose of this study was to identify the structural quality of care domains and to establish a set of structural quality indicators (SQIs) for the assessment of care of older people with cognitive impairment in emergency departments (EDs). A structured approach to SQI development was undertaken including: 1) a comprehensive search of peer-reviewed and gray literature focusing on identification of evidence-based interventions targeting structure of care of older patients with cognitive impairment and existing SQIs 2) a consultative process engaging experts in the care of older people and epidemiologic methods (i.e., advisory panel) leading to development of a draft set of SQIs 3) field testing of drafted SQIs in eight EDs, leading to refinement of the SQI set and 4) an independent voting process among the panelists for SQI inclusion in a final set, using preestablished inclusion and exclusion criteria. At the conclusion of the process, five SQIs targeting the management of older ED patients with cognitive impairment were developed: 1) the ED has a policy outlining the management of older people with cognitive impairment during the ED episode of care 2) the ED has a policy outlining issues relevant to carers of older people with cognitive impairment, encompassing the need to include the (family) carer in the ED episode of care 3) the ED has a policy outlining the assessment and management of behavioral symptoms, with specific reference to older people with cognitive impairment 4) the ED has a policy outlining delirium prevention strategies, including the assessment of patients' delirium risk factors and 5) the ED has a policy outlining pain assessment and management for older people with cognitive impairment. This article presents a set of SQIs for the evaluation of performance in caring for older people with cognitive impairment in EDs.
Process quality indicators targeting cognitive impairment to support quality of care for older people with cognitive impairment in emergency departments
Publisher: Wiley
Date: 03-2015
DOI: 10.1111/ACEM.12616
Abstract: The objective of this study was to develop process quality indicators (PQIs) to support the improvement of care services for older people with cognitive impairment in emergency departments (ED). A structured research approach was taken for the development of PQIs for the care of older people with cognitive impairment in EDs, including combining available evidence with expert opinion (phase 1), a field study (phase 2), and formal voting (phase 3). A systematic review of the literature identified ED processes targeting the specific care needs of older people with cognitive impairment. Existing relevant PQIs were also included. By integrating the scientific evidence and clinical expertise, new PQIs were drafted and, along with the existing PQIs, extensively discussed by an advisory panel. These indicators were field tested in eight hospitals using a cohort of older persons aged 70 years and older. After analysis of the field study data (indicator prevalence, variability across sites), in a second meeting, the advisory panel further defined the PQIs. The advisory panel formally voted for selection of those PQIs that were most appropriate for care evaluation. In addition to seven previously published PQIs relevant to the care of older persons, 15 new indicators were created. These 22 PQIs were then field tested. PQIs designed specifically for the older ED population with cognitive impairment were only scored for patients with identified cognitive impairment. Following formal voting, a total of 11 PQIs were included in the set. These PQIs targeted cognitive screening, delirium screening, delirium risk assessment, evaluation of acute change in mental status, delirium etiology, proxy notification, collateral history, involvement of a nominated support person, pain assessment, postdischarge follow-up, and ED length of stay. This article presents a set of PQIs for the evaluation of the care for older people with cognitive impairment in EDs. The variation in indicator triggering across different ED sites suggests that there are opportunities for quality improvement in care for this vulnerable group. Applied PQIs will identify an emergency services' implementation of care strategies for cognitively impaired older ED patients. Awareness of the PQI triggers at an ED level enables implementation of targeted interventions to improve any suboptimal processes of care. Further validation and utility of the indicators in a wider population is now indicated.
Major trauma in the older patient
Publisher: Wiley
Date: 28-04-2017
Clinical process redesign for unplanned arrivals in hospitals
Publisher: AMPCo
Date: 03-2008
DOI: 10.5694/J.1326-5377.2008.TB01669.X
Abstract: *Emergency department performance had been deteriorating in NSW Health facilities and at Flinders Medical Centre before a fundamentally new approach involving a redesign method, additional bed capacity and more rigorous hospital performance management was applied. *Redesign was undertaken in over 60 hospitals in New South Wales. *Numerous disconnections and misalignments in the process of care delivery have been uncovered during the diagnostic phase of this redesign. *Solutions addressed the entire patient journey through the hospital, to produce smoother patient flow along the continuum of care. *To achieve a sustained improvement in performance, numerous solutions must be simultaneously implemented in each hospital. *With this multipronged approach, a turnaround in NSW emergency access performance has been achieved in the face of rising demand for services the improvement has continued over 3 years. *This article reports on our findings from system-wide redesign for unplanned hospital attendances.
Emergency department transfers and hospital admissions from residential aged care facilities: a controlled pre-post design study
Publisher: Springer Science and Business Media LLC
Date: 12-05-2016
A purple patch for evidence-based health policy?
Publisher: CSIRO Publishing
Date: 2021
DOI: 10.1071/AH21016
Abstract: The global focus on nation states’ responses to the COVID-19 pandemic has rightly highlighted the importance of science and evidence as the basis for policy action. Those with a lifelong passion for evidence-based policy (EBP) have lauded Australia’s and other nations’ policy responses to COVID-19 as a breakthrough moment for the cause. This article reflects on the complexity of the public policy process, the perspectives of its various actors, and draws on Alford’s work on the Blue, Red and Purple zones to propose a more nuanced approach to advocacy for EBP in health. We contend that the pathway for translation of research evidence into routine clinical practice is relatively linear, in contrast to the more complex course for translation of evidence to public policy – much to the frustration of health researchers and EBP advocates. Cairney’s description of the characteristics of successful policy entrepreneurs offers useful guidance to advance EBP and we conclude with proposing some practical mechanisms to support it. Finally, we recommend that researchers and policy makers spend more time in the Purple zone to enable a deeper understanding of, and mutual respect for, the unique contributions made by research, policy and political actors to sound public policy.
Evaluation of the Effect of an Intervention on Potentially Inappropriate Medications (PIMS), Polypharmacy and Anticholinergic Burden Scores for People with Dementia; Results from the SMS Dementia Stud
Publisher: Research Square Platform LLC
Date: 27-07-2020
DOI: 10.21203/RS.3.RS-45859/V1
Abstract: Background People with dementia (PWD) are at risk for medication related harm due to their impaired cognition and frequently being prescribed many medications. Few previous studies of PWD inpatients have been focused on medication safety interventions.This study aimed to evaluate an intervention designed to improve medication safety for people with dementia (PWD) and their carers during an unplanned admission to hospital. This article reports the effect of the intervention on potentially inappropriate medications (PIMs), polypharmacy and anticholinergic burden scores for PWD in the study. Methods A quasi-experimental pre-post design using an intervention site and a control site was conducted in 2017-2019, in a regional area in New South Wales, Australia. PIMs, polypharmacy and anticholinergic burden were measured at admission, discharge and three months after discharge. In addition, medication reconciliation at admission and scoring of pharmacists recommendations using severity and relevance scores were measured. Results There were 628 participants including 350 in the post-intervention phase. Polypharmacy for these admissions was high, and there was approximately 30% reduction in the number of medications at discharge. PIMs at admission were also high, and decreased significantly at discharge however there was no treatment effect associated with the intervention. The mean anticholinergic burden score also decreased significantly between admission and discharge, however, no treatment effect was seen. Conclusions High rates of polypharmacy and PIMs in this study indicate this study population was admitted with multiple comorbidities. Reduced PIMs at discharge were correlated with reduced anticholinergic burden. Medication reconciliation resulted in many recommendations that contributed to the reductions in medications. Although the study did not report a treatment effect, reductions in the number of medications and PIMs reduced medication related risk for PWD. Reduced risks associated with inappropriate or unnecessary medications can reduce hospital admissions and adverse events for PWD. This intervention was feasible to implement, and future multisite studies should be designed to recruit larger study s les to evaluate interventions for improving medication safety for PWD. They should also adopt routine screening for cognitive impairment to identify PWD at admission.
Sepsis in the older person
Publisher: Wiley
Date: 23-03-2018
An evaluation of discharge documentation for people with dementia discharged home from hospital – A cross-sectional pilot study
Publisher: SAGE Publications
Date: 06-09-2017
Abstract: This study evaluated discharge documentation for people with dementia who were discharged home, against expected discharge criteria and determined relationships between compliance scores and outcomes. This cross-sectional study audited discharge documentation and conducted a post discharge survey of carers. There were 73 eligible discharges and clinically significant documentation deficits for people with dementia included: risk assessments of confusion (48%), falls and pressure injury (56%) provision of medication dose-decision aids (53%), provision of contact information for patient support groups (6%) and advance care planning (9%). There was no significant relationship between compliance scores and outcomes. Carer strain was reported to be high for many carers. People with dementia and their carers are more vulnerable and at higher risk of poor outcomes after discharge. There are opportunities for improved provision of medications and risk assessment for people with dementia, provision of information for patient support groups and advanced care planning.
Safe to send home? Discharge risk assessment in the emergency department
Publisher: Wiley
Date: 15-02-2019
Point of care troponin decreases time in the emergency department for patients with possible acute coronary syndrome: a randomised controlled trial
Publisher: BMJ
Date: 03-2010
Abstract: To determine the effect of cardiac troponin I testing with a point-of-care (POC) device versus central laboratory on length of stay (LOS) in emergency department (ED) patients presenting with possible acute coronary syndromes (ACS). A 12-week randomised controlled trial at two metropolitan ED in eastern Australia with a combined annual census of 80,000. Participants were all patients presenting with possible ACS. Exclusions were a diagnosis of ACS before arrival, ST elevation and failure to wait for complete assessment. Randomisation was by week when POC was made available. Primary outcome was LOS from patient arrival to physical departure from the ED. The proportion of patients meeting a government target of less than 8 h stay was compared. Analysis was by intention to treat. Despite underutilisation of POC, LOS was shorter during weeks when it was available. The time savings translates into approximately 48 minutes (95% CI 12 to 84) per average LOS of almost 7 h, which did not reach statistical significance (p=0.063), or an absolute increase of 10% (95% CI 4.3 to 16.6) in the number of people discharged from the ED within the target LOS of less than 8 h, which did reach significance (p=0.007). These savings were more pronounced in the setting without 24 h central laboratory availability. POC testing for troponin in the ED tended to reduce the LOS for possible ACS patients. The degree of this benefit is likely to be markedly dependent on its acceptance and uptake by attending personnel, and on the ED setting in which it is used.
Reducing Hospital Transfers from Aged Care Facilities: A Large‐Scale Stepped Wedge Evaluation
Publisher: Wiley
Date: 30-10-2020
DOI: 10.1111/JGS.16890
Abstract: Older people living in residential aged care facilities (RACFs) experience acute deterioration requiring assessment and decision making. We evaluated the impact of a large‐scale regional Aged Care Emergency (ACE) program in reducing hospital admissions and emergency department (ED) transfers. A stepped wedge nonrandomized cluster trial with 11 steps, implemented from May 2013 to August 2016. A large regional and rural area of northern and western New South Wales, Australia. Nine hospital EDs and 81 RACFs participated in the evaluation. The ACE program is an integrated nurse‐led intervention underpinned by a community of practice designed to improve the capability of RACFs managing acutely unwell residents. It includes telephone support, evidence‐based algorithms, defining goals of care for ED transfer, case management in the ED, and an education program. ED transfers and subsequent hospital admissions were collected from administrative data including 13 months baseline and 9 months follow‐up. A total of 18,837 eligible ED visits were analyzed. After accounting for clustering by RACFs and adjusting for time of the year as well as RACF characteristics, a statistically significant reduction in hospital admissions (adjusted incident rate ratio = .79 95% confidence interval [CI] = .68–.92) P = .0025) was seen (i.e., residents were 21% less likely to be admitted to the hospital). This was also observed in ED visit rates (adjusted incidence rate ratio = .80 95% CI = .69–.92 P = .0023) (i.e., residents were 20% less likely to be transferred to the ED). Seven‐day ED re‐presentation fell from 5.7% to 4.9%, and 30‐day hospital readmissions fell from 12% to 10%. The stepped wedge design allowed rigorous evaluation of a real‐world large‐scale intervention. These results confirm that the ACE program can be scaled up to a large geographic area and can reduce ED visits and hospitalization of older people with complex healthcare needs living in RACFs.
Health professional perspectives on systems failures in transitional care for patients with dementia and their carers: a qualitative descriptive study
Publisher: Springer Science and Business Media LLC
Date: 06-2015
A multi-organisation aged care emergency service for acute care management of older residents in aged care facilities
Publisher: CSIRO Publishing
Date: 2015
DOI: 10.1071/AH15049
Abstract: This case study describes a multi-organisation aged care emergency (ACE) service. The service was designed to enable point-of-care assessment and management for older people in residential aged care facilities (RACFs). Design of the ACE service involved consultation and engagement of multiple key stakeholders. The ACE service was implemented in a large geographical region of a single Medicare Local (ML) in New South Wales, Australia. The service was developed over several phases. A case control pilot evaluation of one emergency department (ED) and four RACFs revealed a 16% reduction in presentations to the ED as well as reductions in admission to the hospital following ED presentation. Following initial pilot work, the ACE service transitioned across another five EDs and 85 RACFs in the local health district. The service has now been implemented in a further 10 sites (six metropolitan and four rural EDs) across New South Wales. Ongoing evaluation of the implementation continues to show positive outcomes. The ACE service offers a model shown to reduce ED presentations and admissions from RACFs, and provide quality care with a focus on the needs of the older person.
Psychosocial Issues in Palliative Care: A Message for Us All
Publisher: Elsevier BV
Date: 03-2010
Diagnosis of urinary tract infection in older persons in the emergency department
Publisher: Wiley
Date: 02-09-2019
Improving access to acute stroke therapies: A controlled trial of organised pre-hospital and emergency care
Publisher: AMPCo
Date: 10-2008
DOI: 10.5694/J.1326-5377.2008.TB02114.X
Abstract: To assess the effectiveness of the PAST (Pre-hospital Acute Stroke Triage) protocol in reducing pre-hospital and emergency department (ED) delays to patients receiving organised acute stroke care, thereby increasing access to thrombolytic therapy. Prospective cohort study using historical controls. Hunter Region of New South Wales, September 2005 to March 2006 (pre-intervention) and September 2006 to March 2007 (post-intervention). Consecutive patients presenting with acute stroke to a regional, tertiary referral hospital. PAST protocol, comprising a pre-hospital stroke assessment tool for ambulance officers, an ambulance protocol for hospital bypass for potentially thrombolysis-eligible patients, and pre-hospital notification of the acute stroke team. Proportion of patients who received intravenous tissue plasminogen activator (tPA), process of care time points (symptom onset to ED arrival, ED arrival to tPA treatment, and ED transit time), and clinical outcomes of patients treated with tPA. The proportion of ischaemic stroke patients treated with tPA increased from 4.7% (pre-intervention) to 21.4% (post-intervention) (P < 0.001). Time point outcomes also improved, with a reduction in median times from symptom onset to ED arrival from 150 to 90.5 min (P = 0.004) and from ED arrival to stroke unit admission from 361 to 232.5 minutes (P < 0.001). Of those treated with tPA, 43% had minimal or no disability at 3 months. Organised pre-hospital and ED acute stroke care increases patient access to tPA treatment, which is proven to reduce stroke-related disability.
Invasive meningococcal disease--improving management through structured review of cases in the Hunter New England area, Australia
Publisher: Oxford University Press (OUP)
Date: 28-07-2009
Abstract: Invasive meningococcal disease (IMD) is the most common infectious cause of death in childhood in developed countries. This disease may cause severe disability or death if a patient is sub-optimally managed. An audit was performed in Australia of all 2005-06 notified IMD cases to elicit correctable issues. Over the 2 year period, 24 cases were notified in the Hunter New England Health area. These cases were reviewed by an expert panel to highlight key correctable issues in recognition and management of IMD. The 24 patients were aged between 1 month and 70 years. Thirteen (54%) were children and 14 (58%) were women. Six (25%) cases developed complications, two being severe (one death, one limb utations). These patients had risk factors for IMD. The emergency department average delay between assessment and administration of antibiotics was 57.8 min. There were avoidable factors identified in both patients with a poor outcome. Length of delay in initiating antibiotic therapy has been associated with poor outcome, thus the delay in our series is of concern. The audit highlighted many potentially correctable issues in the medical, laboratory and public health management of IMD cases.
Nurse-led ED support for Residential Aged Care Facility staff: An evaluation study
Publisher: Elsevier BV
Date: 04-2015
DOI: 10.1016/J.IENJ.2014.11.005
Abstract: To evaluate the impact of a nurse-led telephone support service to Residential Aged Care Facilities (RACFs) on a range of measures relating to the transfer of acutely unwell residents to the Emergency Department (ED) of a large tertiary referral hospital in New South Wales, Australia over a 9 month period. A pre- and post-intervention design determined the impact of the telephone service, associated clinical guidelines and education. Data from 4 intervention RACFs using the nurse-led telephone service were compared with 8 control RACFs. Data included the older patient's triage category, presenting problem(s), transfer rates from RACFs, ED admissions, and overall hospital length of stay. Interviews and focus groups with staff from RACFs and EDs were conducted to ascertain their experiences. Reduced presentations of older people to the ED from the 4 pilot RACFs occurred. High levels of satisfaction among staff in RACFs were reported.
Related Organisations
Australian Commission On Safety And Quality In Health Care
Location: Australia
Australian Commission On Safety And Quality In Healthcare
Location: Australia
Related Funding Activities
No related grants have been discovered for Carolyn Hullick.